Patient portals: start simple, start small

Written by Kate McDonald on 12 September 2014.

Allowing patients to communicate electronically with their GPs through secure, online patient portals is one of the priority areas outlined in New Zealand's National Health IT Plan, although whether they are available to the majority of the population this year remains to be seen.

With the main GP software vendors all now offering patient portal capability and a number of general practice groups and PHOs already having implemented them, the momentum is building towards the plan's eHealth vision, which states that all New Zealanders and the health professionals caring for them should have electronic access to a core set of personal health information by the end of 2014.

For general practices themselves, however, there are a number of challenges to face in setting up and using patient portals, not the least of which is the cost, the time and the difficulty in doing so. As in most areas of healthcare policy, the vision is one thing – the reality is another.

One person who is uniquely situated to advise on the challenges of implementing patient portals is Sue Wells, senior lecturer in health innovation and quality improvement at the University of Auckland's School of Population Health. Dr Wells is a public health physician who spent 10 years in general practice and has a research interest in computerised decision support systems and health informatics, amongst others.

Dr Wells helped develop the PREDICT web-based decision support system for cardiovascular disease risk assessment and the Your Heart Forecast tool, and more recently, she was awarded a Harkness Fellowship to Harvard University, where she undertook a research project about patient engagement and interaction with healthcare services via patient portals.

Part of her research involved interviewing CIOs and clinicians at a number of healthcare organisations that offer patient portals in the US, researching what strategies were most effective in successfully implementing them, what providers thought the value was to the patient and what they were specifically doing in terms of the design, navigation and involvement of patients in their portals.

As well as successful strategies, Dr Wells investigated the main barriers to uptake. While the experience of the US primary healthcare system and its mishmash of private insurers, state, federal and not-for-profit providers cannot be directly applied to New Zealand, some of the lessons certainly can.

“Some of the strategies for implementation are reasonably generic – what worked and what didn’t work at the practice and for frontline care – and that is what I have brought back,” Dr Wells said. “How would this work in New Zealand, what are the key learnings, and what are the major barriers for both patient adoption and provider adoption?”

Those barriers fall into three main categories. While patients are uniformly enthusiastic and positive about the possibilities of using portals and the technology, by far and away the biggest hurdle is getting buy-in from doctors and practices.

“There is the fear about the impact on their workload and the perceived impact on what it would mean for patients,” she said. “They fear it is going to be confusing for patients and that they will be bombarded by patient queries.

“In order for them to buy into this and decide to use it, because it’s such a partnership between them and the patient, there’s got to be a win for the practice and for the clinician. And there are many wins. In fact several large US healthcare organisations reported that this was the best and the most popular intervention (for both patients and providers) that they’d ever introduced."

The second barrier is the workload involved in registering practices and patients. Dr Wells said it was essential that registration processes are streamlined.

“In the States they often had very complicated procedures for the patients. They might send them a password but the patient might lose the letter or forget the password. They would forget how to log in. It might be a temporary password but by the time they get on – because they only get on when they need to get on – it’s out of date.

“So the second big thing that I came back with is yes, it’s got to be a win for the practice, but you’ve got to make it easy for the patient and the practice for registration.

“And the third biggest barrier from the provider perspective was patient access to a computer and their computer literacy. That was way down [in terms of barriers to uptake], but the major innovation being increasingly introduced to reduce the digital divide and the disparities in uptake, was to offer portals through a mobile platform. The use of smart phones was the technology of choice for disadvantaged communities.

“So there are three things: it’s got to be a win, you’ve got to make it easy, it’s got to be mobile.”

When applied to the New Zealand health system, there are other barriers, not the least of which is cost. Not only do practices have to invest money and time in the technology, but they often have to pay for training themselves. Dr Wells suggests that implementing patient portals needs to be looked at from a PHO level, rather than by individual practices.

“This is such good technology, it’s going to potentially benefit a large proportion of our enrolled patients but the cost barriers to practices doing it is high. If the PHOs get together and there’s transparent contracting and pricing, they can work it out that way. I think that on an individual practice basis it’s just too tough.”

While the NZ Health Minister, Tony Ryall, announced last week that $3 million would be made available to help general practices introduce portals, it is unclear as yet how this money will be distributed. It is also unclear if it will overcome the upfront costs of portals, with some vendors charging in the thousands for the technology and associated training, as well as a monthly subscription fee.

Practices may be able to charge patients an annual fee for the convenience of using the portal, but the financial return is yet to be quantified. In addition, patient portals take a huge amount of work to get off the ground.

And it can be a hard sell when it comes to busy practices. Supporters of patient portals make the case that there are many efficiencies to be gained, in particular through the streamlining of prescriptions, appointments and messaging. Portals can do away with telephone tag and can free up doctors, nurses and administrative staff for more important work.

However, no one should underestimate the time it takes to set one up. “My colleagues can see that portals would make a difference, but introducing them into the practice means they have to pay for it, set up new systems and processes, have to organise the security, privacy, brochures and other patient information ... and they’re justifiably wary about all that,” Dr Wells said.

They are also still a little nervous about the change in relationship that patient portals bring, with many remaining suspicious about the worth of providing clinical information to the lay public. GPs also often voice fears about their clinical notes being open to view and prey to misinterpretation.

When she encounters these fears, Dr Wells points to the OpenNotes project set up in the US in 2010. That project has done a lot to dispel fears about what patients would do with access to visit notes. The majority of patients who viewed at least one visit note reported that they understood their health conditions better and were able to remember their plan of care.

Furthermore, three out of four patients said that after reading their notes, they would also take their medications better. Their doctors found that opening up the notes was not an issue at all in terms of extra workload or increased patient enquiries or concerns.

Dr Wells' research in the US has also provided evidence of what patients most value in their medical record.

“Basically, the idea is to start small, start simple, start with something that patients really value," she said. "And the four things that were consistently reported to me from each institution that I investigated were the ability to view lab test results, ask for a prescription, being able to message their doctor and asking for or making an appointment online. They are very simple things that make a world of difference.

“Do some of those things or one of those things – start simple, start small, but start and then look to see whether you want to open your notes. When you look at the OpenNotes project, it was really a non-event for the American doctors."

Dr Wells emphasises that in both New Zealand and Australia, the patient has right to view their medical records; in New Zealand, this is part of the Health Information Privacy Code.

“With all the structural and logistic barriers, very few ever get to see their records, but they do have that fundamental right,” she said.

“It could be said that what portals do is facilitate access to that right for consumers. So we need to start thinking that we are custodians of their data.”

To help overcome some of these problems, Dr Wells is working with the Royal New Zealand College of General Practitioners and the National Health IT Board to develop a range of resources to help guide practices in how to go about setting up a portal, including templates and guidelines for privacy impact assessments and the like.

A shared website is going to be set up to provide these resources to practices so they can learn from the early adopters and don't have to start from scratch.